Provider Demographics
NPI:1083736235
Name:MILLER, GINA BRUNETTI (MS, LCSW)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:BRUNETTI
Last Name:MILLER
Suffix:
Gender:F
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 EAST LAKE CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301
Mailing Address - Country:US
Mailing Address - Phone:573-406-7643
Mailing Address - Fax:
Practice Address - Street 1:3701 E LAKE CTR
Practice Address - Street 2:STE 8
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5842
Practice Address - Country:US
Practice Address - Phone:573-406-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0040761041C0700X
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL073138OtherHEALTH BENIFIT ALLIANCE
IL00132045OtherBLUE CROSS
IL491782OtherVALUE OPTIONS